Provider Demographics
NPI:1093516874
Name:WIETING, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WIETING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MAIN ST STE 409
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6064
Mailing Address - Country:US
Mailing Address - Phone:541-892-7443
Mailing Address - Fax:541-887-2291
Practice Address - Street 1:905 MAIN ST STE 409
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6064
Practice Address - Country:US
Practice Address - Phone:541-892-7443
Practice Address - Fax:541-887-2291
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist